Provider Demographics
NPI:1770585101
Name:WALDORF, TODD R (DO)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:R
Last Name:WALDORF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MILLER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:NY
Mailing Address - Zip Code:12928-2539
Mailing Address - Country:US
Mailing Address - Phone:518-526-9996
Mailing Address - Fax:518-240-4987
Practice Address - Street 1:17 MILLER DRIVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:NY
Practice Address - Zip Code:12928-2539
Practice Address - Country:US
Practice Address - Phone:518-526-9996
Practice Address - Fax:518-240-4172
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217602171100000X, 207Q00000X, 208M00000X, 204D00000X
VT032.0117498208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No171100000XOther Service ProvidersAcupuncturist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
NYPENDINGMedicaid
NYRA5443Medicare ID - Type Unspecified